BOSTON – Medical residents in the United States appear to understand that cardiopulmonary resuscitation or intubation is highly unlikely to benefit patients with advanced cancers at the end of life, but the majority of residents surveyed said that they do not discuss code-status options or potentially beneficial palliative care with their dying patients.
“This was primarily due to residents’ perceptions of patient autonomy: Residents wanted patients to make their own decisions, without any influence from the doctor, which misses the concept of informed decision making. These incomplete discussions can cause at minimum improper documentation of patients’ wishes, and at most psychological harm, damage to the physician-patient relationship, and the potential for unwanted attempts at resuscitation,” said Dr. David J. Einstein, a resident at Beth Israel Deaconess Medical Center and Tufts Medical Center, both in Boston.
Despite their reluctance to have the discussion, however, the majority of residents said they preferred to discuss code status with patients themselves rather than hand it off to the attending physician, primarily out of a sense that it is their responsibility as physicians. Yet these physicians in training did not seem to feel that they were also responsible for providing guidance to patients, Dr. Einstein said at the Palliative Care in Oncology Symposium.
“We felt that this represented an unmet need in training and practice. Residents and attendings should be providing guidance on all medical interventions, including CPR, and if they aren’t sure what to recommend, then they themselves should be seeking guidance from other experts, before asking a patient to falsely choose between an intervention and death,” he said.
The first discussion of code status – do not resuscitate (DNR) or do not intubate (DNI) – may occur in the hospital, and is often left to a resident physician. Ideally, the physician and patient should discuss the patient’s prognosis, goals for care, evaluation of CPR as a means of meeting those goals, and a recommendation. But many residents lack training in the end-of-life discussion, which can have a significant impact on the quality of the patients’ remaining weeks or months of life.
Nationwide survey
Dr. Einstein and his colleagues conducted a nationwide survey to measure the likelihood that residents would discuss prognostic information and offer recommendations to patients with limited life expectancy. They also sought to determine why residents might be reluctant to provide discussion, and to evaluate their satisfaction with code-status discussions that both they and their attending physicians have conducted.
The survey presented respondents with a hypothetical case of a patient with stage IV adenocarcinoma of the lung metastatic to the brain. The patient, who has disease progression despite receiving first- and second-line therapy, presents to the emergency department with dyspnea and is slightly hypoxemic, but is not in distress. The patient has not previously established a code-status preference.
The investigators contacted 387 residency program directors by mail, 19 of whom agreed to participate and responded. They sent surveys to a total of 1,627 residents, 358 of which were completed and included.
The investigators found that slightly less than half of the respondents said they would share information with the patient about his/her prognosis and the relative benefit of CPR, and more than two-thirds said they would be unlikely to offer a specific recommendation.
“So even in the situation with a clearly declining patient, residents were as likely as not to provide the information needed to make an informed decision, and were far less likely to provide guidance on this decision,” Dr. Einstein said.
Asked the reason for their decisions, 69% of the residents who would not offer a recommendation said that the patient should make his/her own decision without any influence, and 26.5% said that the attending would not want them to offer a recommendation. Nonetheless, only 1.3% of this group said they believed that CPR would offer the patient a reasonable chance of resuscitation.
The majority of respondents who would offer a recommendation (93.5%) said they would recommend DNR and DNI.
Code-status talk a ‘responsibility’
When they were asked whether they would prefer the attending to discuss code status, nearly 70% of respondents disagreed.
Of those residents who said they preferred to retain the code-status discussion, 93.4% said they thought it was part of their responsibility as a physician, and 65.8% said they thought they had sufficient training and knowledge to do it. A minority in this group (2.5%) said that they would be likely to disagree with the attending’s estimate of prognosis, and 4.9% said they thought the attending would not share his/her estimate honestly.